An Enhanced Method for Left Bundle Branch Area Pacing Lead Extraction Using Continuous Femoral Pigtail Countertraction

<b>Background:</b> Left bundle branch area pacing (LBBAP) has emerged as a physiological alternative to conventional pacing, offering improved ventricular synchrony and clinical outcomes. However, extraction of deeply implanted LBBAP leads remains challenging, particularly in the context of device-related infections. <b>Case Summary</b>: We report two cases of successful extraction of chronically implanted LBBAP leads using a novel technique based on femoral countertraction with pigtail catheters. In the first case, a deep septal implanted 3830 lead was extracted in a patient with persistent bacteremia and suspected device-related endocarditis. Continuous traction was applied to the mid-portion of the lead using a pigtail catheter introduced via femoral access, facilitating safe removal without the use of powered sheaths proximal to the distal tip of the lead. In the second case, three leads (RA, RV, LBBAP) from a cardiac resynchronization therapy with deffibrilation support (CRT-D) system were completely removed in a patient with device extrusion and pocket erosion, using a dual pigtail approach anchored to the atrial and septal leads. <b>Results:</b> In both cases, the technique enabled successful extraction without complications. Procedural times were approximately 70 and 65 min, respectively. In vitro testing suggested that the pigtail catheter applied a sustained moderate traction force (~0.06 kgf), translating to an estimated pressure of 0.85-1.91 kgf/cm² at the septal lead interface. <b>Conclusions:</b> This case series demonstrates that LBBAP lead extraction is feasible using a novel femoral countertraction technique with pigtail catheters. Steady, moderate traction over time may provide a safer alternative to forceful subclavicular extraction, especially in chronically implanted deep septal leads. Further studies are warranted to evaluate the reproducibility, safety, and clinical applicability of this approach.